Basic Information
| Provider Information | |||||||||
| NPI: | 1669482907 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FARRELL | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 S 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012884329 | ||||||||
| FaxNumber: | 6015795240 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 S 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012884329 | ||||||||
| FaxNumber: | 6012883191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 08/23/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 14920 | MS | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 640507572AR | 01 | MS | AMERICAN ADMIN GROUP | OTHER | 110122927 | 01 | RAILROAD MEDICARE | OTHER | 1419664 | 05 | LA | MEDICAID | 000117297 | 05 | MS | MEDICAID |